Part 1 – Clinical Skills

Finger extension Extensor digitorum Radial nerve C7 Part 1 – Clinical skills CHAPTER 1 HISTORY AND EXAMINATION Dr William P. Howlett 2012 Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania BRIC 2012 University of Bergen PO Box 7800 NO-5020 Bergen Norway NEUROLOGY IN AFRICA William Howlett Illustrations: Ellinor Moldeklev Hoff, Department of Photos and Drawings, UiB Cover: Tor Vegard Tobiassen Layout: Christian Bakke, Division of Communication, University of Bergen E JØM RKE IL T M 2 Printed by Bodoni, Bergen, Norway 4 9 1 9 6 Trykksak Copyright © 2012 William Howlett NEUROLOGY IN AFRICA is freely available to download at Bergen Open Research Archive (https://bora.uib.no) www.uib.no/cih/en/resources/neurology-in-africa ISBN 978-82-7453-085-0 Notice/Disclaimer This publication is intended to give accurate information with regard to the subject matter covered. However medical knowledge is constantly changing and information may alter. It is the responsibility of the practitioner to determine the best treatment for the patient and readers are therefore obliged to check and verify information contained within the book. This recommendation is most important with regard to drugs used, their dose, route and duration of administration, indications and contraindications and side effects. The author and the publisher waive any and all liability for damages, injury or death to persons or property incurred, directly or indirectly by this publication. CONTENTS HISTORY AND EXAMINATION 13 HISTORY TAKING 13 NEUROLOGICAL EXAMINATION 16 CRANIAL NERVE EXAMINATION 16 EXAMINATION OF THE LIMBS 28 EXAMINATION OF THE GAIT �� 36 CONSCIOUSNESS �� 37 KEY TO BASIC NEUROLOGICAL EXAMINATION 41 CHAPTER 1 HISTORY AND EXAMINATION Introduction Neurology relies on the fundamental skills of history taking and physical examination. The aim of this section is to help the medical student to learn the basic clinical skills necessary to carry out a neurological history and examination and interpret the findings. Most students find neurology difficult to remember and in particular what to do, how to do it and what it all means. The history is the most important part of neurological evaluation because it is a guide to the underlying disease and also determines which part of the examination needs to be focused on. Indeed many neurological diseases like migraine have symptoms but no abnormal signs. The neurological examination determines abnormal neurological findings and helps to localize the site of the disease (Chapters 2 & 12). The history, examination and localization all together help to determine which disease has occurred at that site. The necessary competence required to carry out these tasks is formed by a combination of knowledge, skills and experience. Neurological knowledge is mostly self learned while clinical skills are taught at the bedside and experience gained over time. The nervous system by its nature is complex but its assessment can be learned with patience, plenty of practice and time. HISTORY TAKING Introduction The history is the most important part of the neurological assessment. The student should aim to be a good listener showing interest and sympathy as the patient’s story unfolds. It is important to get the patient’s trust and confidence. First introduce yourself to the patient, explain who you are and ask permission to take a history and to carry out an examination. Find out the patient’s name, age, address, occupation. Determine handedness by asking which hand do you write with or use more often. Some clinical findings are apparent to the examiner during history taking; these include general state of health and obvious neurological deficits and disabilities. If there is alteration in the level of consciousness or the patient is unable to give a history then it may be necessary to obtain a history and witnessed account from a relative or friend before proceeding directly to neurological examination. The patient’s history reveals his personality, intelligence, memory and speech and his body language his attitude and mood. The questions should aim to learn the character, severity, time course and the particular circumstances of each main symptom. The order of history taking is summarized below under William Howlett Neurology in Africa 13 CHAPTER 1 HISTORY AND EXAMINATION CHAPTER 1 HISTORY AND EXAMINATION key points. While the history is being taken the level of alertness, mental well being and higher cerebral function becomes apparent to the examiner. Key points in a neurological history · age, sex, occupation, handedness · past history · presenting complaints · family history and social history · history of presenting complaints · drug history · neurology system review questions · gynaecological and obstetrical history Presenting complaint Start the formal history by asking the patient to state what the problems are and the reason for hospital admission or referral. This could begin with open questions such as “what is the main problem or “tell me about it from the start”. Try to let the patient tell the story of the illness as it has happened without any interruption. Make certain that you understand clearly what the patient is describing by their complaints. Determine the order of the presenting complaints, these should ideally not number more than three or four and be in order of importance. For each complaint determine the main site, character, onset, time course, exacerbating and relieving factors, associated symptoms and previous investigations and treatments. Key points · what are the problems · site, character, time course, exacerbating & · what is the main problem relieving factors, associated symptoms · when did it start · previous investigations and treatments Time course The time course of symptoms is essential to understanding the underlying cause. Ask the patient to describe the onset, progress, duration, recovery and frequency of each main complaint. In particular ask if the onset was sudden over seconds or minutes as occurs in stroke or more slowly over weeks or months as occurs in mass lesion e.g. tumour. Describe progress whether it was stationary as in a stroke or worsening as in an infection or intermittent as in epilepsy. If the symptoms are intermittent enquire about their frequency and the interval between them. Ask about precipitating or relieving factors, associated neurological symptoms and any particular circumstances in which the symptoms occur. Key points · onset · frequency · progress · recovery · duration Systems review A systematic enquiry may reveal symptoms related to the patient’s illness. This may include a general medical review in addition to neurological systems review. Carry out a neurological systems review by asking the patient specific screening questions concerning symptoms 14 Part 1 – Clinical skills Neurological Examination HISTORY TAKING affecting the various levels of higher cerebral and nervous system functioning. Finally ask if there is anything else that the patient would like to tell you. Neurology systems review key questions · change in mood, memory, concentration or · weakness or heaviness in limbs sleep · difficulty walking · pain, headache, face or limbs · pins and needles or numbness in arms, legs or · loss of consciousness or dizzy spells body · loss of vision or double vision · difficulty with passing urine, bowels and · loss of hearing or balance sexual function · difficulty speaking or swallowing Interpretation As the history unfolds the examiner begins to hypothesize about the meaning of the history and the cause of the disorder. To reinforce this information it may be necessary to rephrase the questions in different ways or ask some direct questions. The main potential sites of disease are the brain, spinal cord, cranial and peripheral nerves, neuromuscular junction and muscles. It is helpful to attempt to anatomically localize the main site of the disease. Defining an anatomical limit to main symptoms is also helpful e.g. the upper limit of a sensory level in paraplegia, or the motor loss on one side in hemiplegia, or the glove and stocking sensory loss in a polyneuropathy. If the amount of time is limited then it is better to spend time on the history and be selective about the examination concentrating it on the main areas of interest. Past medical history (PMH) Enquire about past medical illnesses and accidents including hospitalizations and operations, and record their details in the notes. Where relevant ask specifically about a history of infections, seizures, head injuries, birth and childhood development, diabetes, hypertension and stroke. Enquire if there is a past history of neurological episodes similar to the presenting complaint and outline any investigations, their results and treatments received, and any persisting disabilities. Family history Document the patient’s first degree relatives i.e. parents, siblings and children including their ages, sex and health. Enquire if there is anyone else in the family with the same illness, if so record the full family tree with their names and

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